The present research explored the effect of an educational program based on the health belief model (HBM) on prisoners’ HIV preventive behaviors in the south of Iran. The present quasi-experimental research was conducted in 2019–20 on 280 prisoners, 140 in the control group (CG) and 140 in the intervention group (IG).
(2022) 22:1342 Hosseini et al BMC Public Health https://doi.org/10.1186/s12889-022-13763-z Open Access RESEARCH The effect of a theory‑based educational program on southern Iranian prisoners’ HIV preventive behaviors: a quasi‑experimental research Zahra Hosseini1, Pirdad Najafi2, Shokrollah Mohseni1, Teamur Aghamolaei3 and Sara Dadipoor4* Abstract Background: The present research explored the effect of an educational program based on the health belief model (HBM) on prisoners’ HIV preventive behaviors in the south of Iran Methods: The present quasi-experimental research was conducted in 2019–20 on 280 prisoners, 140 in the control group (CG) and 140 in the intervention group (IG) The sampling was simple randomized The data were collected using a questionnaire in two parts, one exploring the demographic information and the other the HBM constructs The final follow-up was completed 3 months after the educational intervention (8 sessions long) in November 2020 Results: After the intervention, statistically significant between-group differences were found in the healthy behavior score and all HBM constructs except for the perceived barriers (p 0.05) However, after the educational intervention, the between-group difference was statistically significant (p 0.112 P-value 0.698 0.001> Intervention 20.77 ± 5.13 29.19 ± 1.97 0.001> Control 21.84 ± 5.07 22.47 ± 4.93 0.164> P-value 0.082 0.001> Intervention 22.41 ± 5.47 19.76 ± 3.20 0.001> Control 21.72 ± 5.68 20.58 ± 6.39 0.070> P-value 0.299 0.179 Intervention 21.69 ± 6.16 29.24 ± 1.99 0.001> Control 22.11 ± 4.94 23.04 ± 4.63 0.109> P-value 0.522 0.001> Intervention 17.40 ± 4.22 24.04 ± 1.94 0.001> Control 17.05 ± 4.73 17.84 ± 4.50 0.127> P-value 0.514 0.001> Intervention 22.93 ± 4.35 31.85 ± .739 0.001> 0.059> Control 23.26 ± 5.77 24.03 ± .6.369 P-value 0.591 0.001> Table 4 Analysis of covariance to adjust the pre-intervention scores as the covariate Variables Perceived susceptibility Source Sum of Squares df Mean Square statistic F p-value Partial Eta Squared baseline score 1.40 1.40 157 692 001 intervention 1968.050 1968.050 220.623 000 443 error 2470.960 277 8.920 R Squared = .444 (Adjusted R Squared = .440) Perceived severity baseline score 331.328 331.328 25.513 000 084 intervention 3343.666 3343.666 257.466 000 482 error 3597.351 277 12.987 R Squared = .493 (Adjusted R Squared = .489) Perceived benefits baseline score 627 627 049 825 000 intervention 2689.980 2689.980 210.166 000 431 error 3545.416 277 12.799 R Squared = .432 (Adjusted R Squared = .427) Perceived barriers baseline score 252.736 252.736 10.201 002 036 intervention 60.665 60.665 2.449 119 009 error 6862.621 277 24.775 R Squared = .042 (Adjusted R Squared = .035) Self-efficacy baseline score 4.676 4.676 388 534 001 intervention 2677.917 2677.917 221.984 000 445 error 3341.610 277 12.064 R Squared = .446 (Adjusted R Squared = .442) Behavior baseline score 2116.404 2116.404 162.966 000 370 intervention 4473.805 4473.805 344.490 000 554 error 3597.332 277 12.987 R Squared = .640 (Adjusted R Squared = .638) Hosseini et al BMC Public Health (2022) 22:1342 Page of 10 Table 5 Predictors of AIDS preventive behavior based on the HBM model Variables B 95.0% Confidence Interval for B Lower Bound Upper Bound Standardized Coefficients Beta t p-value Perceived susceptibility 289 112 466 193 3.211 001 Perceived severity 536 384 687 451 6.97 0.001> Perceived benefits 232 091 373 183 3.24 0.001> Perceived barriers −.117 −.228 −.006 −.099 −2.082 038 Perceived Self-efficacy 161 005 −.006 125 2.035 005 R Square = 0.400 Adjusted R Square = 0.411 severity of the adverse effects of HIV show more protective behaviors According to Rosen Stock’s theory, perceived severity can promote preventive and medical measures in individuals [25] As put forth by Bakhtiari, one who perceives him/herself at the risk of a major problem, takes a serious measure to protect oneself [26] The present findings showed that the mean score of perceived benefits was significantly increased in the IG compared to the CG Similarly, a body of research reported the effectiveness of education in increasing the perceived benefits of HIV preventive behaviors [14, 16, 27] Contrary to the present findings, in a number of studies, perceived benefits was not correlated with HIV preventive behaviors [22, 28] Different purposes of research and socio-demographic features in different geographies can be other potential reasons for the different findings As an instance, in the study conducted by Gharlipour et al., probably failed HIV therapeutic measures canceled out the effect of the educational intervention on the participants’ perceived benefits Our educational intervention, however, evidently highlighted the benefits of preventing HIV and managed to encourage people to adopt preventive healthy behaviors We also found that the educational intervention had no effect on perceived barriers This is consistent with a number of studies that reported the ineffectiveness of educational interventions in HIV preventive behaviors and adherence to medications [14, 22] Contrary to this finding, some other studies found an increase in perceived barriers after the educational intervention [20, 27, 29] Different types of barriers in different studies (physical, financial, psychological and social) can also account for the divergent findings No increase in the perceived barriers score in the present study was quite expected because, as also reflected in the questionnaire items, most barriers were out of an individual’s control Naturally, in only one educational intervention, we were unable to overcome such personal barriers that required higher-order interventions such as organizational, social and even political Of note is that in this research, a lower perceived barrier score was accompanied by a higher rate of healthy behaviors Thus, it can be expected to be effective in the adoption of healthy behavior The present findings also revealed a higher mean score of self-efficacy in the IG than CG in the posttest This is consistent with a number of studies which also reported an increase in the self-efficacy score after the educational intervention [14, 27] Another study showed that self-efficacy was significantly and strongly correlated with HIV preventive behaviors in Thai youngsters [12] Furthermore, self-efficacy has proved to be key to the reduced rate of high-risk AIDS-related behaviors [30] In contrast, in two other works of research by Smith and Bandora [31] and Zamboni [32]., education showed to have no effect on patients’ self-efficacy [22] Improving self-efficacy was suggested as a secondary goal for lowering the rate of HIV infection According to the socio-cognitive theory, those with a lower self-efficacy stand higher chances of showing risky behaviors [27] As expected in our research, those with a higher self-efficacy showed more HIV-AIDS preventive behaviors [28] Thus, improving prisoners’ self-efficacy can to a large extent prevent the incidence rate of HIV The present findings showed an increase in the participants’ score of HIV preventive behaviors in IG compared to CG after the intervention Similarly, other studies reported the effectiveness of adopting HIV preventive behaviors and adherence to medications [16, 22] It can be argued that the educational intervention could have positively affected the participants’ healthy behavior by affecting the HBM constructs as the mediating factors Limitations, strengths and suggestions for future research The present research was conducted on male prisoners in the south of Iran; thus, the generalization of the findings to other populations especially women is limited To increase the generalizability, future research needs to include comparable male and female samples in areas with different cultural and socioeconomic features The short-term follow-up was another limitation Hosseini et al BMC Public Health (2022) 22:1342 Therefore, it is suggested that the participants be followed up for at least a year to assess their consistency of behavior Another limitation of this research was the self-reporting nature of the questionnaire The participants might have produced socially desirable responses which can threaten the integrity of responses Still, we attempted to ensure the subjects of the confidentiality of the information they provided to maximize their honesty The data were collected anonymously to reduce the biased responses A lack of access to confidential prison information, including the number of HIV-infected inmates and drug abuse in prisons, were among the other limitations of the present study There were certain strengths as well For instance, the theory employed (i.e., the HBM) was a systematic framework to explain the healthy preventive behavior This theory clearly described the key concepts included in the intervention [33] Making a goal-oriented and theory-based intervention, selecting a highrisk research population and having a control group are among the other strengths of the present research Implications As there is no definite cure for HIV infection and there has been no theory-based educational intervention for the target research population (i.e., prisoners), the present findings can significantly contribute to the existing literature They pave the way for future comparative HIV-related research and can help policy makers develop better interventional programs to prevent HIV-related risky behaviors in the light of relevant theories Conclusion The present research showed the effectiveness of HBM in adopting HIV preventive behaviors among prisoners The educational intervention managed to positively affect the prisoners’ healthy behaviors by affecting the HBM constructs first As the results showed, the educational intervention had no effect on perceived barriers, which was quite expected, as perceived barriers could not be removed until the end of a simple short-term intervention To remove barriers to the adoption of healthy behaviors, researchers should develop multi-level interventions to gain more desirable outcomes We particularly aim to implement goal-oriented educational programs based on health education and promotion frameworks to prevent HIV behaviors Abbreviations HBM: Health belief model; IG: Intervention group; CG: Control group Page of 10 Supplementary Information The online version contains supplementary material available at https://doi. org/10.1186/s12889-022-13763-z Additional file 1 Education and training content Additional file 2 Acknowledgements The authors would like to thank Hormozgan University of medical science for their financial support The authors would also like to express gratitude to the participants for their sincere cooperation Authors’ contributions Z.H designed the study, supervised data collection, analyzed the data and reviewed the manuscript; S.D designed the study, collected data, analyzed the data, drafted the manuscript and critically reviewed the manuscript; P N designed the study and reviewed the manuscript; SH M analyzed the data and reviewed the manuscript; T.A., S.D., Z.H reviewed the manuscript All authors read and approved the final manuscript Funding This research received a grant from Hormozgan University of medical science Availability of data and materials The datasets used and/or analyzed during the study are available from the corresponding author on reasonable request Declarations Ethics approval and consent to participate The study conformed with the WMA of Helinski and the Nuremberg Code It was also approved by the Ethics Committee of Hormozgan University of medical sciences (#IR.HUMS.REC.1398.112) All participants provided written informed consent before entering the study Consent for publication Not applicable Competing interests None to declare Author details Social Determinants in Health Promotion Research Center, Hormozgan Health Institute, Hormozgan University of Medical Sciences, Bandar Abbas, Iran 2 Student Research Committee, Hormozgan University of Medical Sciences, Bandar Abbas, Iran 3 Cardiovascular Research Center, Hormozgan University of Medical Sciences, Bandar Abbas, Iran 4 Infectious and Tropical Diseases Research Center, Hormozgan Health Institute, Hormozgan University of Medical Sciences, Bandar Abbas, Iran Received: 18 December 2021 Accepted: July 2022 References The Global HIV Epidemic https://www.kff.org/global-health-policy/fact- sheet/the-global-hivaids-epidemic SeyedAlinaghi S, Leila T, Mazaheri-Tehrani E, Ahsani-Nasab S, Abedinzadeh N, McFarland W, et al HIV in Iran: onset, responses and future directions AIDS (London, England) 2021;35(4):529 Gharaei HA, Fararouei M, Mirzazadeh A, Sharifnia G, Rohani-Rasaf M, Bastam D, et al The global and regional prevalence of hepatitis C and B co-infections among prisoners living with HIV: a systematic review and meta-analysis Infect Dis Poverty 2021;10(1):1–17 Defante Ferreto LE, Guedes S, Braz Pauli F, 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University of medical science Availability of data and materials The datasets used and/or analyzed during the study are available from the corresponding author on reasonable request Declarations Ethics... review and meta-analysis Iran J Public Health 2019;48(2):217 Akbari M, Akbari M, Naghibzadeh-Tahami A, Joulaei H, Nasiriyan M, Hesampour M, et al Prevalence of HIV/ AIDS among Iranian prisoners: a. .. to and severity of the disease [15] HBM constructs can apply to HIV educational programs, and raise awareness of HIV preventive behaviors [16] A body of research has proved the effectiveness of